Ddx Chart Part 1

1 Acne and Related Disorders( Chart1of 1) Acne vulgaris Presentation

Inflammation of the pilosebacuous(area around hair follicle) glands or specific surfaces.(Face, back, trunk) Occurs most frequently in adolescence but may occur in adulthood(1017years in Females and 14-19years in Males)

Acne Rosacea Chronic acneiform disorder: vassular dililation of central face: Nose Cheek Eyelids Forehead Background erythema

Acute cutaneous Lupus Erythematous(SLE) Inflammatory connective tissue disease which is multifaceted with a wide range of manifestations ranging from chronic skin lesions(Discoid LE) to widespread polymorphos lesions(Subacute cutaneous LE) to multiple organ involvement(Systemic LE) Woman are affected more than men(8:1)

Distribution

Predominantly on face, back, shoulders and chest

Central facial area

Lesions

Primary -Open comedomes (Blackheads;lipid has oxidized)

Primary -Papules, pustules, nodules, cysts telangiectasia (later)

-Closed comedomes White head

Secondary -Erythema -Scarring

More frequent in people in 30-40 age range Sun exposed areas(face, arms, chest, shoulders, backs or hands etc.) Superficial to indurated(becoming hard and firm) Non puritic

-Papules -Pustules -Nodular cysts

Erythmatous to violacceaous (red to violet colored) plaques appear

Special lesions -Rhinophyma (hyperplasia of the soft tissues of the nose. (Nose appears larger)

May be scaling on surface

Flushing
Serious multisystem disease: may be fever, arthritis, renal, cardiac, pulmonary and central nervous system involvement In laboratory Can screen for underlying antinuclear Ab(ANA), blood count, urinalysis

In 10-15% of patients, a butterfly rash appears over malar and nasal bridge

Secondary -Erythema -Scar -Excoriation(scratching) Signs/Symptoms Dx

-Clinical appearance -Age -Can do hormonal panel

History

May appear with out any history of acne or seborrhea Affects individuals 30 years or older; often

2 of Celtic origin Duration

-Can wax and wane in adulthood

DDx

-May persist to age 35 or older Folliculitis

Contact dermatitis

Acne rosacea

Rosacea Tinea Erysipelas

Other

Seborrheic dermatitis Pathology The dysregulation of T cells causes activation of B cells which produce a variety of anutoanitbodies directs towards cellular antigens(DNA, RNA, RNA protein complexes)

Aggrivating factors/risk factors -Drugs(lithium, adrogens, topical and systemic corticosteroids and oral contraceptives -Endocrine imbalance(thyroid, insulin, sex hormones) -Malabsorption, HCL deficiency, liver or color problems Emotional considerations -Self-rejection, anger, fear, boundaries

Bullous, Vesicular Diseases( Chart 1 of 1) Pemphigus vulgaris(pemphix=bubble) Presentation

Bullous Perphigoid

Dermatitis herpetiformis(clustering)

Erythema Multiforme(wide variety of lesions)

A potentially fatal autoimmune siease characterized by destruction of the desmosomes of stratified squamous epithelium of mucus membranes and skin

-A chronic blistering autoimmune disease(idiopathic) -Attachment of basal cells to basement membrane is selectively damaged Commonly affects people 60yoa or older

Chronic recurrent Pruritic eruption on extensor surfaces occurring often in symmetric groups and including three types of lesions -Vesicles -Papules -Urticarial wheals

General term for diverse reaction patterns of blood vassels in dermis with secondary epidermal changes

Incidence 1/1000,000 and usually occurs in middle or older aged individuals

-Occurs twice as often as pemphigus vulgaris -Less aggressive than Pemphigus vulgaris and is not life threatening

“Multiforme” refers to a wide variety of lesions

3

Distribiton

Lesions

Localized -mouth Generalized -scalp -face -chest -axillae -groin Pirmary -Bullae Secondary -Erosions -erythema

Widespread blistereing eruption in a older patient who is taking multiple medications Flexural areas -Groin -Axillae Oral involvement Occurs in 1/3 of cases

Primary -Bullae -Urticarial(hives) plaques Secondary -Erosions -Erythema

Lesions -Skin colored -Round or oval -Randomly scattered

Extensor surfaces -Sarcum -Elbows -Knees -Lower back -Shoulders

-Symmetric

Primary Vesicles Papultes Uriticarial wheals Plaques

Primary Papules Plaques

Secondary Excoriations Erythema Often no intact primary lesions are seen because of the intense pruritis and excoriations

Mucous membranes -Erosions of mouth, nose, pharynx, larynx ad vagina

-Predilection for dorsum of hand, tops of feet, soles -Also on forearms, feet, face, penis and vulva

Secondary Erythema Lesions - blanch with pressure -Vesicles and bullae in center of papule -Iris or target shaped lesions -Central clearing

Signs/Sx

Painful Bullae are rarely seen No pruritis Weakness, malaise, weight loss if prolonged mouth involment

Puritis may be present

-Puritis

-Localized to hands or generalized Severe fever

-Intense episodic burning or stinging of skin

Sever prostration(complete physical or mental exhaustion)

-Gluten enteropathy in most patients

Mild form -Little or no mucus membrane involvement -No bullae or systemic Sx -Eruptions usually confined to extensor surfaces

-Local symptoms(pruritis and stinging of skin) precede appearance of skin lesions by 8-12 hours

Severe form

4 -Most often occurs as a drug reaction -Always involves mucous membrane

Dx

Based on Positive Nikolsky’s sign (+)dislodging of epidermis with the lateral aspect of the finger in area of lesions results in an erosion and pressure on bullae leads to lateral extension of bullae (blister breaks when you apply pressure)

Deep shave or punch biopsy from intact bulla to reveal subepidermal bullae

Clinical eruption of sever itching, burning and stinging

Positive Nikolsky’s sign(like Pemphigus Vulgaris)

On extensor surfaces Biopsy PMNs (polymorphonucleocytes) and subepidermal blister formation

-Confirmed by biopsy and examination for IgG deposits between epidermal cells History

Often associated with gluten intolerance / sensitivity Lesions last days to weeks

Duration DDx

Other

Dermatitis Herpetiformis Apthae (canker sores) Erythema multiforme

Tx -Systemic corticosteroids(prednisone) -Immunosuppressant agents(methotrexate) -Referral

Pemphigus vulgaris(not purities, mucous membrane is involved and rarely are bullae intact.

Scabies Excoriated eczema Insect bites

Lesions last several days Target lesions are quite typical and Dx is not difficult In absence of skin lesions Mucus membrane lesions must be DDx with -Bullous diseases -Fixed drug erruption Stevens-Johnson’s syndrome -Severe erythema multiforme with extensive mucosal erosions, target-like lesions and skin blisters. Almost total loss of epidermis known as toxic epidermal necrolysis.

5 -Often associated fever and malaise. Commonly affects oral cavity, pharynx, conjunctiva and anogenital regions Urticaria(Chart 1 of 1) Urticaria(burning) Presentation

From Latin “to burn” and the nettle species Urtica which produces a stinging sensation of the skin when contacted. Common condition characterized by Pruritic, transient hives or wheals as a result of vasodilation and subsequent fluid leakage into the dermis

Distribution Lesions

Signs/Sx Dx

Lesions change in size and shape Can be oval, arciform, annular, and as coalesce; serpiginos Individual lesions last less than 24hrs Wheals Erythema Edema Angiodema(Allergic skin disease characterized by patches of circumscribed swelling) -involvment of deeper tissues with predilection for mucus membrane When taking history, include onset, medications, environmental changes, foods, illness Acute Urticaria Lesions are present for less than 6 weeks Chronic Urticaria Lesions last longer than 6 weeks

History

Duration DDx Other

Generalized Urticaria May be life-threatening and involve major organ systems Underlying cause is identifiable in less than 25-50% of cases -Circulating Ag(drugs, inhalants, stress) -Physical or environmental exposure(i.e. cold urticaria which occurs during re-warming, pressure urticaria) Individual lesions last less than 24hrs Erythema multiforme Insect bites Dermatographism (Hives appear after scraping skin) ND Approach Identify food sensitivities Adrenal support

6 Immune support Papilloquammous Diseases( Chart 1 of 2) Allergic/Contact Dermatitis

Nummular eczema(Discoid eczema)

Lichen Simplex Chronicus

Atopic Dermatitis

Localized form of lichenification usually occurring in circumscribed plaques

Atopy (out of place) Pruritic skin disorder involving cutaneous hypersensitivity

Presentation

Acute vesicular dermatitis with in a few hours to 72 hours after contact.

Chronic, puritic inflammatory dermatitis occurring in the form of coin shaped plaques

Distribution

Site of contact

Regional clusters of lesions or generalized.

Lesions

Primary Vesicles, bullae, papules and wheals Secondary Erythema, edema, exudate, excoriation, fissures, lichenification and hypopigmentation

Sign

Only in area of exposure, history important

Symptom

Puritis

Predilection; lower legs and trunk Primary Closely grouped, small vesicles and papules that coalesce into plaques 4-5cm in diameter Erythematosus base Distinct borders Secondary Excoriation and lichenification Worse in fall or winter

Puritis

Dx

Predilection for the flexural surfaces, front and side of the neck, eyelids, forehead, wrists and dorsa of feet and hands Scaling is limited Excoriations are often present Palpably thicker skin

Primary/acute phase Plaques, papules –Skin appears puffy and edematous(swollen) Secondary Erythema, scale excoriation, fissures, crusts and lichenification in chronic lesions

Skin markings are accentuated and more visible

Chronic scratching

The itch that rashes. Constant scratching leads to a cycle of itch→scratc→itch which leads to lichenification(rough skin) rash of the skin Can have periorbital pigmentation from compulsicely rubbing the eyelids Atopic individuals may also have allergies, allergic rhinitis, asthma, elevated levels of IgE Puritis Dry skin

History

History of exposure to allergen or related compound

Ask person how it initially presents before they scratch.

Personal history of allergic rhinitis Family history of atopic dermatitis Early age of onset(
7 Variable disease course Duration

Resolves with in 21 days

DDx

Nummular eczema Atopic eczema Scabies

Psoriasis Contact dermatitis

Lesions persist for months and/or years Seborrheic dermatitis Psoriasis Scabes

Image Papillosquammous Diseases( Chart 2 of 2) Lichen Planus Presentation

Distribution

Characterized by a polygonal violaceous(violet) papules and plaques

Mouth Genitals Volar wrists(bracelet)

Seborrheic Dermatitis

Psoriasis

Pityriasis Rosea

Common, chronic erythematosus scaling eruption of unknown cause that affects all age groups but usually affects adults 20 years or older

An itching condition Common hyperproliferative inflammatory disorder of unknown cause Results in rapid cell turnover in the epidermis(1000x than normal)

Eruptive dermatitis that primarily affects people age 10-35 Suspected to be of viral origin

Occurs in regions where the sebaceous glands are most active -Face -Scalp -Body folds

Can be single lesion or lesions localized to one area(i.e penis, nails) or it can be regional(i.e. scalp)

Scalp involvement is commonly known as dandruff in adults and cradle cap in infants

Often spares exposed areas(palms)

Yellowish red often greasy scaling macules and papules(5-20mm)

Nail involvement -Pitting of nails, oil spot(yellowbrown)

Herald Patch -Several cm in diameter and can mimic tinea corporis

Sticky crusts are common when scalp, external ear, axillae and groin are involved

-Distal separation of the nail plate from the bed (onycholysis)

-Oval, slightly raised dull red plaque, bright red with a fine collarette/centripical scale at periphery

Characteristic eruption usually begins with a herald patch on the trunk 1 to 2 weeks prior to the onset of the truncal eruption Trunk Upper extremities Rarely on face

Unilateral or bilateral

Ankles May be generalized Symmetrical

Lesions

Nails may be involved(varies from minor dystrophy to total nail loss) Papules and plaques Post inflammatory hypopigmentation(similar to a scar)

Nummular, annular or trunk shape

Favors elbows, knees, intertriginous (where 2 surfaces rub together) areas and scalp

-Scale forms underneath nail plate

- Herald patch occurs in 80% if

8 Scattered, discrete arrangement on face and trunk Diffuse arrangement on scalp

Skin lesions -Sharply demarcated papules and plaques -well developed lesions have a thick silvery scale -Peeling off the scale will reveal pinpoint bleeding from capillaries close to the top layer of skin(Auspitz’s sign)

patients -Herald patch is followed by generalized secondary eruption Generalized eruption -Plaques, papules, erythematous scale, hyperpigmentation in dark skinned patients -Scales tend to be centrally located Exanthum: Fine scaling papules and plaques with typical marginal collarette(scaling around edge)

Signs

Whickham’s striae (white lace like patterns on surface of papules and plaques). Not always present

Pityrosporum ovale (a normal yeast flora is thought to play a role)

Initially appears in people under 20 yoa but can occur at any age Thick silvery scale

Feels very hard and can often affect genitals

Auspitz’s sign

Symptoms Dx

Based on lesions appearance a characteristic location

Clinical appearance of typical erythematous papules and plaques with a thick silvery scale

With buccal involvement look for Wickham’s striae

Characteristic distribution; trunk and upper extremities Appearance of central scale(exanthemous lesions)

Deep shave or punch biopsy may be necessary History Duration DDx

Other

Family history common Psoriasis Lichenoid drug eruptions

May or may not have mild to severe puritis Based on clinical history, the presence of Herald Patch(not always present)

Often history of URTI Self-limited Guttate psoriasis Eczema(discoid) Tinea corporis Drug eruption

Psoriasis Candidiasis Acne rosacea Butterfly rash of SLE(Systemic lupus Erythematosus) Forms

9 Guttate Sudden onset of small scattered tear drop schaped papules and plaques after a streptococcal infection as a child or young adult(URTI) Ask Px, “Where you sick prior to the skin irruption?” Pustular Occurs on the hands and feet including the nails(toenails and fingernails) Trigger factors -Kobner’s phenomenon(physical trama will lead to the development of a plaque) -Infections -Stress -Drugs -Diet high is arachidonic acid, cGMP cycle